According to the American Academy of Pain Medicine, pain now affects more people in the U.S than diabetes, heart disease, and cancer combined. While chronic pain has been around as long as humans, diagnosis of pain has grown due to increased awareness and better diagnostic instruments.
Along with an increase in diagnosis comes an increase in prescription opioids used to control pain.
Even though opioids are not recommended as a treatment for chronic pain, the number of prescriptions for this purpose rose sharply between the years of 2000 and 2009. When prescriptions rose, so, too, did opioid dependence, abuse, and overdose. In response to this, the Centers for Disease Control (CDC) have introduced new opioid prescribing guidelines aimed at sharply reducing the number of people who take opioids in the U.S. Not everyone is on board with these guidelines, and there is more than one perspective to this story. Pain News Network, in particular, has provided thorough coverage on the topic and we encourage you to read their take on the situation on their website as well.
At Pain Doctor, we feel that is important to note that, unlike the myths that would say otherwise, the vast majority of chronic pain patients are not taking opioids for pain management. Opioid prescriptions for non-cancer pain peaked in 2010 and then began to decline as healthcare providers and patients worked together to find alternate ways to treat chronic pain.
These new guidelines, based on opioid research from 2010, include the following provisions:
- Use of non-pharmacological therapy as the “preferred” method of pain management
- Drug testing before and during opioid use
- Smaller doses for shorter periods of time (with “three days or fewer” being the general rule, and only for acute pain)
Other guidelines include specific instructions regarding counseling patients on the risks and potential benefits of opioids, careful and frequent monitoring of any changes in use of opioids (frequency or amount), and a thorough review of a patient’s medical history to predict any potential issues with previous substance abuse.
For some patients who do take opioids for pain management, these new guidelines are not welcome.
Many have tried other forms of non-pharmacological interventions with no success and worry that they will no longer be able to function if guidelines are tightened and prescriptions become harder to get. The CDC held a 48-hour online comment period, and many patients urged them to reconsider their new guidelines.
Writes one patient:
“It is already difficult to get my prescriptions that I have been safely using for years. If these additional restrictions of prescriptions, need for monthly doctor visits, etc. are put into place, I will only suffer more. Legitimate pain patients are not the problem, yet are greatly impacted by guidelines such as this.”
Another writes about the ease with which a friend turned to the street when legal opioids became harder to obtain:
“I have a friend who eventually became addicted to heroin when NY state made it hard for her to get tramadol. It was easier for her to get street drugs for her back injury pain.”
Patient advocates in the pain community also question the use of research they feel is misleading and wonder why the CDC is getting involved in the territory of the Food and Drug Administration. Janice Reynolds, a retired nurse and activist in the pain community, does not believe that the CDC’s involvement is warranted or that the new guidelines have the patient’s best interest at heart:
“The CDC knows nothing about pain management and possibly less about pharmacology, so why should anyone listen to them? Their complaints against opioids only increases the misery of people with pain and does little to prevent deaths as most people with an addiction to prescription medications obtain their meds not by legitimate prescriptions.”
Still another perspective is that of the prescribing doctors themselves. For pain management specialists, safely returning patients to a healthy, pain-free life is of paramount importance.
Many pain doctors have already put into place their own guidelines to assess options and appropriately prescribe opioids when the benefit outweighs the risk.
Pain Doctor currently uses a 12-step opioid therapy checklist that includes some aspects of the new guidelines, including taking a thorough patient history to identify potential dependence risks and appropriate complementary, non-pharmacological therapies where indicated. We believe in a calibrated, holistic approach to pain management, and for some of our patients that includes opioid therapies. Many doctors also voluntarily enact their own guidelines for prescribing opioids.
Until the guidelines are formally published, it is difficult to say what impact they may have on current practices, but in general, the vast majority of pain doctors want to keep their patients safe while treating their pain. If these new guidelines help to do that, pain doctors may embrace the changes.
Others are not fond of the wait-and-see approach. Because these guidelines were developed under somewhat secretive conditions, many community members are also not on board. Even though the guidelines are clear that they are aimed at non-cancer chronic pain, the American Cancer Society (ACS) sent the CDC a letter expressing their concerns about the guidelines and the implications in the language for cancer patients. They are concerned about the process from start to finish, saying that:
“[They] believe the proposed guidelines have the potential to significantly limit cancer patient access to needed pain medicines. [The American Cancer Society has] concerns about the lack of evidence on which the guidelines were based, the methodology used to develop the guidelines, and the transparency of the entire process.”
The Washington Post also initially withheld its support for the new guidelines but went on record in the opinion section on October 20th, stating that these new guidelines from such a respected national governmental body may be exactly what states need to decrease the number of opioid prescriptions overall:
“It’s true, as the [American Cancer Society] letter notes, that the CDC guidelines are more than mere suggestions and will influence ‘state health departments, professional licensing bodies or insurers.’ That is precisely why they can be so beneficial; until now, government, medicine and the private sector have too often underestimated the risks, individual and societal, of widespread opioid prescription. The CDC has the prestige and authority to correct the balance.”
It is important to understand that some of the guidelines are aimed at new patients only. For example, a patient currently taking over 90 milligrams of opioids daily for pain would not necessarily be held to the dosage limits set forth under the new guidelines.
As of October 21st, the CDC was still reviewing and revising the guidelines for prescribing opioids, and the final draft may be quite different due to feedback from patients, pain advocates, doctors, and community members. The Centers for Disease Control estimates publication of the guidelines early in 2016.
What do you think about the new rules?